coordinating care among stakeholders to raise healthy …the first 1000 days •rapid change in...

Coordinating Care Among Stakeholders

to Raise Healthy Families

Dr. Jennifer S. Savage, Assistant Professor of Nutritional Sciences

Interim Director, Center for Childhood Obesity Research

The Pennsylvania State University, University Park, PA

Annual Meeting of the Society of Behavioral Medicine

April 2 2016

Symposium Objectives

• Discuss community and clinical care

stakeholders’ beliefs regarding roles and

responsibilities for care domains and their

attitudes toward electronic data coordination

solutions

• Highlight key lessons learned on developing

systems to coordinate coordinating care

between clinical and community providers

• Discuss the importance of mental health

screening in community and clinical settings

and how coordinating care will improve health

services

1 of 3 children in the United States

are overweight or obese before age 5

The Problem

1Pan, et al., JAMA, 2012; 2012;308:2563-25652Finkelstein, et al., Am J Prev Med, 2012

1 of every 7 low-income preschool aged

children in the US is obese1

In less than 2 decades

42% of today’s kids will be obese2

The first 1000 days

• Rapid change in diet, metabolic, and behavioral

systems are opportunities

• Early onset obesity comorbidities are more serious

• Infants and toddlers don’t tend to “grow out of it”

• Dietary patterns are established early in life

• Experimental studies suggest promising strategies for

early obesity prevention (T1 and T2)

*Summerbell et al Cochrane review, 2005 ;Harris et al, 2009; Haynos & O’Donohue, 2012

The Intervention Nurses Start Infants Growing

on Healthy Trajectories (INSIGHT) Study

• Ongoing Randomized Controlled Trial

• Recruit first time mothers from labor

and delivery

• Nurse home visits, videos, mailings

Study protocol: Paul et al. 2014 BMC Pediatrics

Primary Aim: To test the efficacy of an intervention designed to prevent

rapid weight gain in infancy and overweight at 3 y by providing guidance

on responsive feeding and healthy dietary choices.

INSIGHT Intervention Components

Responsive Parenting

Sleep

Feeding

Fussing and

Soothing

Active

Social Play

Lower weight-for-length percentile at 1y

in parenting intervention group

0

5

10

15

20

25

30

35

< 5 5-10 10-25 25-50 50-75 75-90 90-95 ≥ 95

Pe

rce

nt

Weight-for-length percentile at 1 year

Parenting

Contol

5.5% in parenting

infants

12.7% of control

infants were

overweight

Overweight =

weight/length ≥95th

percentile

*Kolmogorov Smirnov Two-Sample Test p<0.01;

Savage et al. presented at PAS meeting, 2015; In Preparation, 2015

Next step: translation to broader population

• Large trials like INSIGHT demonstrate program efficacy,

but....

• Expensive, not feasible on large scale

• Home delivery intervention

• Homogenous population – highly educated, high income,

low depression

• Inclusion criteria: first time mothers

• May not translate well to other populations

• How do we translate to broader populations?

1Redsell et al. 2015 Mat Child Nutr; 2Paul et al. 2011 Obesity; 3Wen et al. 2012 BMJ

Goal of R40

Develop an individually-tailored behavioral

intervention designed to prevent overweight

among low-income infants by providing

coordinated, personalized care on responsive

parenting across multiple settings.

Mom and Infant

GeisingerPediatrician

WIC Nutritionist

Goal of R40

Coordination of care is definition:

• Deliver the same, consistent messages

• Providers will communicate preventive care plans

and education with each other

3-5 day 1 mo 2 mo 6 mo 9 mo 12 mo

WCV X X X X X X

WIC X X X X X

Research Project Overview

• Phase 1

• Focus groups

• Data sharing, integration, display

• Training

Y1Phase 2

Recruitment Observational

then RCT

Y2• Data

analysis

• Manuscripts

• Next GrantY3

Phase 1 Lessons Learned: Formative Research

1. Establishing an interdisciplinary team that includes

community partners takes TIME and requires administrative

leadership

Establishing an Interdisciplinary Team

that includes Community Partners

• Center for Childhood Obesity Research

• Geisinger Health Systems Obesity Institute

• Maternal and Pediatric Obesity Research

• Department of Pediatrics

• Center for Clinical Innovations

• EPIC programmers

Interdisciplinary Team Members



• American Academy of Pediatrics

• Sandra Hassink, President, American Academy of Pediatrics

• Janice Liebhart: Evaluation Manager, Institute for Healthy Childhood

Weight

• Alison Baker: Institute for Healthy Childhood Weight

• Jeanne Lindros, Manager, Institute for Healthy Childhood Weight

Sandra Hassink, MD





• Women, Infants, and Children

• Shirley Sword: Chief, Nutrition Services Section

• William Cramer: Director, WIC

• Greg Johnson: IT, WIC

• Local agency

Shirley Sword, MS, RD





• Women, Infants, and Children

• INSIGHT intervention PIs

Ian Paul, MD, MScProfessor of Pediatrics and Public

Health Sciences

Chief, Division of Academic

General Pediatrics

Leann BirchProfessor of Nutrition

University of Georgia

Phase 1: Formative Research

1. Establishing an interdisciplinary team that includes community

partners

2. Stakeholders we have spoken with:

• Focus groups: WIC nutritionists (n = 35)

• Interviews: Primary care providers (n = 15)

• Interviews: GHS patients/WIC parents: (n = 28)

• Interviews were transcribed and grounded-theory approach was

used to independently open-code transcripts. Categories were

identified and emerging themes reported.

Phase 1: Lessons learned from parents

• Dislike the rigidity of the nutrition education provided by the

WIC program

• Receive conflicting information from WIC, health care providers

and their own families

• Think “every baby is different” and “I know best, instincts” when

making decisions about feeding and caring for infant or toddler

• Want more individualized messages on feeding and caring for

their child.

Savage et al. (under review) Maternal and Child Nutrition

Phase 1: Lessons learned from Community

Nutrition and PCP

Data sharing: WIC nutritionists and pediatricians were enthusiastic about sharing and having access to data (e.g., progress note, immunizations, anthropometrics, formula)

Coordination of care

WIC:

• Conflict in messaging is prevalent (not clear the source: mother reporting bias or actual doctor reports… “grapevine effect”)

• Concerns: time management/work flow, and technology access (i.e., web access)

GHS Primary Care Providers:

• Value feeding guidance provided by WIC, but disagree with some WIC policies/guidance (e.g., juice)

• Conflict in anthropometric measures between PCP and WIC

• Have little concern about time to review WIC information


Nutrition and PCP

Who is the expert?

• WIC nutritionists reported trivializing their training as the

expert by deferring to the physicians (“ask your

physician”).

• Mothers/caregivers trust advice based on relationship;

less dependent on credentials

• Both WIC and Pediatricians express that “it takes an army

to parent a child” and that responsive parenting guidance

is a shared responsibility.


Nutrition and PCP

Depression

• WIC (half willingly) expands practice to screening for

depression. Concerns about not being trained and lack of

resources/referral procedures. Need for formal training

• Doctors report being unprepared to handle mental health

referrals

• Scope of practice: parent chart is hard to get

Maternal psychosocial factors (e.g., depression)

may also influence feeding behavior and child weight

• Depression rates are high among low-income mothers (40-59%)

• Some evidence shows that depressed mothers are:

• Less sensitive and more negating to their children (Murray et al. 1996)

• More likely to endorse a non-responsive feeding style (Hurley et al.,

2008) and tend to have heavier children (Gross et al. 2013)

X

Savage. 2015. Pediatric Obesity

Research Project Overview

• Phase 1

• Focus groups

• Data sharing, integration, display

• Training

Y1Phase 2

Recruitment Observational

then RCT

Y2• Data

analysis

• Manuscripts

• Next GrantY3

Phase 2: Randomized Controlled Trial

| 25

Mom and Infant

PCPWIC

Mom and Infant

PCPWIC

Treatment (n=145):

Responsive Parenting Curriculum

Personalized Messaging

Data Sharing

Care Plan Coordination

Standard of Care Control

(n=145)

Intervention components: Responsive Parenting

•Name (child/parent)

•Date of birth

•Child’s health insurance

•WIC participant

•Brand and product name of formula

•Breastfeeding status

•Hemoglobin/Hematocrit

•Length/Weight

•Food allergies

•Special pediatric conditions

•Neurological and psychiatric disorders

•Gastrointestinal disorders

•Hepatic, pancreatic, and

biliary disorders

•Endocrine disorders

•Nutrition disorders

•Musculoskeletal disorders

•Cancer

•Renal disorders

•Cardiovascular disorders

•Immunizations

•Well child visit date

•WIC visit date

Intervention Components: Data Sharing

Intervention Components: Early Healthy Living (EHL)

Screening Tool to provide clinical decision support to

personalize messaging

• Examples of Care Coordination Topics

Intervention Components: Coordinated Care

Conceptual view of Epic (PCP View)

EHL Topic Patient-Reported Data (Report

Date: 11/01/15)

Topic

Discussed

during WCV

Beverages in past

week

Formula; 100% Juice

WIC Discussion (Report Date:

10/07/2015): Beverages

Child put to sleep

(start/end)

8:00 PM/12:00 AM

WIC Discussion (Report Date:

10/07/2015): Sleep Routine

WIC Note: Reoccurring topic. Co-

sleeping. Family stressor.

| 29


Conceptual view of Quick WIC (Nutritionist View)

| 30



| 31



| 32

Summary of Lessons Learned

• Conflict in messaging was commonly reported by all stakeholders, but the majority were enthusiastic about sharing and having access to data

• A challenge has been establishing a health information exchange platform (i.e., data management system) and data sharing agreements

• Data sharing agreements among state/federal agencies, health care systems, and academics take months to execute

• IT support is critical for data sharing: Epic and Quik WIC Systems

• Need for mental health screening, referral/treatment operating procedures, and provider training

• Stay tuned for efficacy results…

Questions?

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